Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African
American single w oman w ho presents for a pre-
Patient is in no apparent distress. Alert and oriented
employment physical. She is the primary source of
x4. Patient is seated upright on the examination
the history. Ms. Jones offers information freely and
table, she is w ell nourished, and dressed
w ithout contradiction. Speech is clear and coherent.
appropriately for the w eather with good hygiene.
She maintains eye contact throughout the interview .
https://app.shadowhealth.com/assignment_attempts/4562098 1/7
Dow nloaded by chue morris (chuemorris45@gmail.com)
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